Provider Demographics
NPI:1548283765
Name:SMITH, LARRY EDWARD (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601884
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1884
Mailing Address - Country:US
Mailing Address - Phone:980-487-1148
Mailing Address - Fax:704-487-7753
Practice Address - Street 1:1124 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3862
Practice Address - Country:US
Practice Address - Phone:980-487-1148
Practice Address - Fax:704-487-7753
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94-01047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC77269OtherNCBCBS
SCN01049Medicaid
NCP00389982OtherMEDICARE PIN - RAILROAD
NC8977269Medicaid
NC1548283765Medicaid
SCN01049Medicaid
NC2205106DMedicare PIN
NC2205106EMedicare PIN
NCNCE360AMedicare PIN
A77554Medicare UPIN